Social Services Donation Form

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About Social Services Donation

In March 2012, the Manhattan City Commission passed Resolution 032712-A, authorizing the creation of a utility donation program for social services. As a result, city staff has developed a program to allow residents to make a recurring donation, on monthly utility bills, to help support social service agencies in Manhattan. If you would like to participate, please fill out the form below.

Authorization *

I authorize the City of Manhattan’s Customer Service Department to add the amount listed below to each month’s city utility bill in support of local social service agencies in Manhattan, Kansas. I understand that this donation will continue each month as directed below. Further, I also understand that if my utility bill is delinquent for two (2) consecutive months, my monthly donation will cease immediately.

Yes

No

Name:*

Water Account Number (without dashes):*

What amount would you like to be added to your monthly utility bill for donation to Social Services in Manhattan?*

(Must be in whole dollar amounts and a minimum donation of $1 please)

Please choose one of the following. *

This monthly donation continues until I no longer require water service at the address noted below.

This monthly donation shall end on the date listed below.

Address:

Date:

Contact Information*

Please provide a phone number or email to be used in the event that there are any questions regarding your donation.